Notification of Changes for Business Entity
General Information
Business Entity Name:	NORTON AGENCY INSURANCE, LLC
Incorporation / Formation Date:
FEIN:	581656177
Ohio License Number:
NPN:
DBA / Trade Name:
State of Domicile:	GA
County:	HALL
Business Address
Address 1:	434 GREEN STREET
Address 2:
City:	GAINESVILLE
State:	GA
Zip:	30501
Phone:	6785535283
Fax:
Business Web Site Address:
Business Email Address:
Mailing Address
Address 1:	P.O. BOX 2976
Address 2:
City:	GAINESVILLE
State:	GA
Zip:	30503
Indicate the type of change you are seeking
Address Change:	NO
Business Entity Name Change:	NO	Old Business Entity Name:
New DBA/Trade Name:	NO	New DBA/Trade Name:
Amend DBA/Trade Name:	NO	Old DBA/Trade Name:
Add/Delete Producers, Members, Owners, Partners, Officers and/or Directors:	YES

Licensed Producers
Name	Title	NPN	Add	Delete	Eff. Date

Members, Owners, Partners, Officers and Directors
Name	Title	Identifying #	Add	Delete	Eff. Date
RAINMAN, INC	MEMBER	582296964		YES	07/28/2016

Title Business Entities Only
1. Is any member, producer, owner, share holder, manager, partner, officer or director currently engaged in deriving income from or affiliated with (other than as a customer) any business or profession other than insurance? (i.e. banking, auto dealer, mortgage company)
2. Has any member, producer, owner, share holder, manager, partner, officer or director currently engaged in deriving income from or affiliated with (other than as a customer) any business or profession other than insurance since the filing of the previous CN-65 or the original application?
3. If the answer to questions #1 or #2 is yes, identify the business or profession and the nature of person's involvement

Submitted By
Submitted By:	LEANNE MILLS - ILSA
Title:	CLIENT LIAISON SERVICES
Phone Number:	2547296141
Email Address:	LMILLS@ILSAINC.COM